Evolution of the anterior intrapelvic (Stoppa) approach for acetabular fracture surgery

Division of the iliac vessels in the anterior intrapelvic approach to acetabular fracture

INTRODUCTION

The modified Stoppa approach is gradually becoming the gold standard in pelvic ring and acetabulum surgery. One of the potential intraoperative complications is vascular injury. The aim of this study was to identify the level of division of common iliac vessels with respect to a bone landmark, their inter-individual variability and their correlation with morphological criteria.

MATERIAL AND METHODS

This was a single-center continuous retrospective study of patients who had preoperative CT angiography for pelvic fracture between February 2017 and May 2018. The level of arterial and venous division and the angle of vein division were measured bilaterally for each patient from the most antero-inferior part of the sacroiliac joint on multiplanar reconstruction and standardized analysis. Relationships with morphological data (age, gender, BMI, height), anterior column fracture and deep venous thrombosis were analyzed.

RESULTS

The right arterial division level was 50±16mm (-2.35; 96) from the landmark and the left arterial division level 44±14mm (0; 80). The right venous division level was 30±12mm (-9; 75) and the left venous division level 30±13mm (-5; 66). The right venous bifurcation angle was 65±18° (22; 119) and the left venous bifurcation angle 68±17° (18; 117). The arterial division level was significantly higher on the right side (p=0.007). There were no significant correlations with morphological data.

CONCLUSION

The great inter-individual variability of iliac vessels should prompt analysis of their morphology on routine imaging when planning pelvic surgery using the modified Stoppa approach, in order to anticipate the risk of bleeding.

LEVEL OF EVIDENCE

IV; cases series.

Extra-articular screw placement strategy in Stoppa approach based on three-dimensional reconstruction model

The study aimed to explore an extra-articular screw placement strategy in Stoppa approach. Radiographic data of patients who underwent pelvic computed tomography from January 2016 to June 2017 were imported into Materiaise's interactive medical image control system software for three-dimensional reconstruction. Superior and lower margins of acetabulum and ipsilateral pelvic brim could be observed simultaneously through inlet-obturator view. A horizontal line from superior acetabular margin intersected pelvic brim at point "A" and another vertical line from lower margin intersected pelvic brim at point "B" were drawn, respectively. Lengths form sacroiliac joint to "A" (a), "A" to "B" (b), and "B" to pubic symphysis (c) were measured. Patients were divided into four groups depending on gender and side difference of measured hemi-pelvis: male left, male right, female left, and female right. Lengths of adjacent holes (d) and spanning different holes (e) of different plates were also measured. Mean lengths of a, b, c in four groups were 40.94 ± 1.85 mm, 40.09 ± 1.93 mm, 41.78 ± 3.62 mm, and 39.77 ± 2.23 mm (P = 0.078); 40.65 ± 1.58 mm, 41.48 ± 1.64 mm, 40.40 ± 1.96 mm, and 40.66 ± 1.70 mm (P = 0.265); 57.03 ± 3.41 mm, 57.51 ± 3.71 mm, 57.84 ± 4.40 mm, and 59.84 ± 4.35 mm (P = 0.165), respectively. Mean d length of different plates was 12.23 mm. Average lengths spanning 1, 2, 3 and 4 holes were 19.33 mm, 31.58 mm, 43.80 mm, and 55.93 mm. Our data showed that zones a and c could be safely inserted three and four screws. Penetration into hip joint could be avoided when vacant 3-hole drilling was conducted in zone b. Fracture line in zone b could serve as a landmark for screw placement.

Corona mortis and pelvic dissection: Understanding the relationship between anatomical structures and bone areas

Pelvic fractures are becoming increasingly frequent. The gold standard for surgical managements remains open procedures. Despite its excellent biomechanically results, it can lead to many complications. Minimally invasive surgery could reduce these complications. For complex pelvic trauma, extraperitoneal endoscopic technique has never been described. The aim of this study is to determine anatomical landmarks which are useful for endoscopic pelvic ring surgery using an extraperitoneal approach. The second objective is to compare this minimally invasive procedure to expose the bone versus a traditional open approach. After preparing the vessels with latex injections, 10 specimens are dissected alternately, using an endoscopic method (MIS) on one side and an open method on the other side. Both procedures are performed on the same subject. The visualized bone areas are drilled with burr holes. The marked surfaces are measured with photogrammetry. Finally, the data are processed (surface analysis). An extraperitoneal endoscopic dissection that follows anatomical landmarks can be performed. Bone area (mm2 ) visualized by endoscopy was 74 ± 14 (59-94) compared to 71 ± 16 (48-94) by open method. Paired t-test was performed with no significant difference between the two methods. Skin and muscular incisions were significantly lower in the MIS group (5.1, IC95% [4.1; 6.1], p < 0.001). An extraperitoneal endoscopic dissection of the pelvis can be performed. We also find no significant difference between our method and an open traditional approach concerning bone exposure. We offer a holistic approach to treat pelvic fractures by identifying key anatomical structures.

Hands-free Femoral Traction Using the Bookwalter Retractor System During Anterior Approaches to the Acetabulum

SUMMARY

Displaced acetabular fractures with medial and cranial displacement of the femoral head commonly require an anterior approach for reduction and stabilization. Restoration of the femoral head to its native position under the reduced acetabular dome is a primary goal of surgery. We present a surgical technique for applying traction to the proximal femur using the Bookwalter retractor system during the repair of acetabular fractures when using an anterior approach. By placing traction in line with the femoral neck, the femoral head is moved to a more anatomical position allowing acetabular fracture fragments to be reduced unimpeded and the femoral head may be used as a reconstructive template. We review a case series of 116 patients treated using this technique and report the short- and long-term radiographic and clinical results of treatment.

Nonunion of an Undisplaced Lateral Compression Type 1 Pelvic Ring Fracture due to Interposition of a Tension-Free Vaginal Tape: A case report

CASE

Nondisplaced lateral compression type 1 fractures of the pelvic ring are usually treated nonoperatively. We describe a case of nonunion after conservative treatment of such a fracture in a healthy 59-year-old female patient due to the interposition of a tension-free vaginal tape in the fracture gap. An anterior intrapelvic approach with plate osteosynthesis was used to stabilize the fracture once the tape was removed from the fracture gap. After 3 months, the fractures had healed and the patient was pain-free.

CONCLUSIONS

Previous urogynecologic interventions should be routinely inquired about and considered in anterior pelvic ring injuries.

A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients

Aim and objective

To study the radiological and functional outcomes as well as complications in the management of fractures involving both columns of the acetabulum using a single surgical approach.

Design

Type IV, prospective clinical study.

Setting

Level I trauma centre.

Materials and methods

Inclusion criteria were as follows: (a) patients over 20 year of age and (b) patients suffering from acetabular fractures involving both columns as per Letournel and Judet classification, namely transverse, transverse + posterior wall, T type, anterior column posterior hemi-transverse (ACPHT) and associated both columns. Exclusion criteria were as follows: (a) patient suffering from isolated anterior column, posterior column, anterior wall, posterior wall and posterior wall + column fractures; (b) patient who have undergone surgical procedures of the hip prior to trauma; and (c) compound acetabular fractures. A total of 23 patients having both column acetabulum fractures were included prospectively from June 2016 to December 2018 and followed up till 1 year postoperatively. Open reduction and internal fixation were performed through one of three described approaches, i.e., iliofemoral, Kocher-Langenbeck, and anterior intrapelvic or ilioinguinal.

Results

Our study population consisted of 30.4% transverse, 39.1% associated both columns, 21.7% T type and 8.7% anterior column + posterior hemi-transverse. Of these, 65.2% were operated using the Kocher-Langenbeck approach, while 30.4% of patients required the anterior intrapelvic approach. The remaining 4.3% of patients were operated by the iliofemoral approach. Anatomic reduction was achieved in 100% of our study population with remaining displacement less than or equal to 1°mm. At 1-year follow-up, all fractures showed a satisfactory union with an excellent Matta index in 100% study subjects. Complications at 1 year included one case of foot drop, which was present preoperatively but failed to improve and one case of post-traumatic arthritis. Average Harris Hip score (HHS) and mean Merle D'Aubigne (MDA) scores suggested good clinical outcomes in the study population.

Conclusions

A single approach can be used to achieve good functional and radiological outcomes in carefully selected bicolumnar fractures of the acetabulum, with less approach-related morbidity.

Clinical significance

Traditionally, multiple approaches are used for acetabulum fractures involving both columns, but with proper patient selection, single approach can be used with good functional and surgical outcomes.

How to cite this article

Patil A, Attarde DS, Haphiz A, et al. A Single Approach for Management of Fractures Involving Both Columns of the Acetabulum: A Case Series of 23 Patients. Strategies Trauma Limb Reconstr 2021;16(3):152–160.

Anatomical Considerations in Percutaneous Fixation of the Pelvis and Acetabulum

Reduction and fixation techniques of the pelvis and acetabulum continue to evolve. There has been increased use of percutaneous and minimally invasive techniques in the past several decades. Although offering many advantages to traditional open techniques, percutaneous techniques still place nearby structures at risk, making a thorough understanding of the applied surgical anatomy essential.

Treatment of anterior column posterior hemitransverse fracture with supra-ilioinguinal approach

Objective

To report the feasibility and effect of the supra-ilioinguinal approach for treatment of anterior posterior hemitransverse fracture of the acetabulum.

Methods

Nineteen consecutive patients who underwent treatment for an anterior column posterior hemitransverse fracture of the acetabulum from January 2013 to June 2018 were retrospectively analyzed. All patients underwent treatment by the single supra-ilioinguinal approach with at least 1 year of follow-up.

Results

The mean time to surgery, operative time, incision length, and blood loss were 10.2 ± 3.8 days, 157 ± 125 minutes, 10.2 ± 0.6 cm, and 876 ± 234 mL, respectively. According to the Matta scoring system, the reduction quality was excellent in 13 patients, good in 6, and poor in 0. According to the Merle d'Aubigné scoring system, the outcome at the last follow-up was excellent in 12 patients, good in 5, fair in 1, and poor in 1. Postoperative complications occurred in three patients (deep vein thrombosis in one, lateral femoral cutaneous nerve injury in one, and both complications in one).

Conclusions

Use of the supra-ilioinguinal approach for treatment of anterior column posterior hemitransverse fracture of the acetabulum produced excellent clinical results because of the direct visualization of the anterior column and quadrilateral plate.

Single column plate plus other column lag screw fixation vs. both column plate fixation for anterior column with posterior hemitransverse acetabular fractures - a biomechanical analysis using different loading protocols

OBJECTIVES

Open reduction and internal fixation of both columns is considered the treatment of choice for displaced anterior column with posterior hemitransverse (ACPHT) fractures in non-geriatric patients. Plate fixation of one column combined with lag screw fixation of the other column allows to decrease operative time and approach-related morbidity compared to conventional both column plating. The aim of this biomechanical study was to evaluate whether single column plate plus other column lag screw fixation confers similar stability to both column plate fixation. Physiological loads were simulated using both the single-leg stance (SLS) as well as the sit-to-stand (STS) loading protocols.

METHODS

A clinically relevant ACPHT fracture model was created using fourth-generation composite hemipelves. Fractures were stabilized with three different fixation constructs: (1) anterior column plate plus posterior column screw fixation (AP+PCS), posterior column plate plus anterior column screw fixation (PP+ACS) and anterior column plate plus posterior column plate fixation (AP+PP). Specimens were loaded from 50 to 750 N with a ramp of 100 N/s. Fracture gap motion (FGM) and relative interfragmentary rotation (RIFR) between the three main fracture fragments were assessed under loads of 750 N using an optical 3D measurement system.

RESULTS

STS loading generally resulted in higher mean FGM and RIFR than STS loading in the AP+PCS and AP+PP groups, while no significant differences were found in the PP+ACS group. Compared to conventional both column plate fixation (AP+PP), PP+ACS displayed significantly higher FGM and RIFR between the iliac wing and the posterior column during SLS loading. No significant differences in FGM and RIFR were identified between the AP+PCS and the AP+PP group.

CONCLUSION

Overall, single column plate plus other column lag screw fixation conferred similar stability to conventional both column plate fixation. From a clinical point of view, AP+PCS appears to be the most attractive alternative to conventional AP+PP for internal fixation of ACPHT fractures.

Medium-Term Patient-Reported Quality of Life and Activities of Daily Living in Surgically Treated Trauma Patients With Pelvic, Acetabular or Combined Pelvic and Acetabular Fractures in a Retrospective Single-Center Study

OBJECTIVE

To gain more insights in the medium-term patient-reported quality of life (QoL), activities of daily living (ADL), and number of complications in trauma patients with an acetabular fracture (AF), a pelvic fracture (PF), and those with a surgically combined pelvic and AF (PAF).

DESIGN

Retrospective single-center study.

SETTING

Level I academic trauma center.

PATIENTS/PARTICIPANTS

51 trauma patients with PF, AF, or PAF who were surgically treated between 2014 and 2017.

INTERVENTION

Open reduction and internal fixation.

MAIN OUTCOME MEASUREMENTS

Primary outcome measures are patient-reported outcome questionnaire, which includes 2 items, the QoL, as measured with the Short Form-12, and the ADL, as measured with the Lower Extremity Functional Scale. The secondary outcome parameter was the occurrence of complications during a follow-up of at least 2 years.

RESULTS

The mean physical component score (PCS) of the QoL (P = 0.03) and the ADL (P = 0.03) were significantly higher in patients with AF compared with patients with PF. The incidence of the overall postoperative complications did not significantly differ between the PF, AF, and PAF groups (P = 0.28).

CONCLUSIONS

This study found that the PCS of the QoL and the ADL in surgically treated trauma patients with PF were significantly lower compared with patients with AF. No significant differences were found in overall complication rate between the PF, AF, and PAF groups.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Anterior approach to the sacroiliac joint for pelvic ring fractures: Technical note

Displaced pelvic fractures, combining an anterior lesion and sacroiliac disruption, most often require multiple surgical approaches. The technique we describe here allows these lesions to be treated by a single approach. It combines a Stoppa approach to address the anterior lesion and a pararectus approach to the sacroiliac joint through the same incision under the rectus abdominis muscle. This pararectus approach is done by passing laterally to the external and common iliac vessels. The entire anterior surface of the sacroiliac joint is exposed by the same passage through the abdominal wall. No neurological or vascular complications occurred in a 7-patient case series. Reduction was achieved in all cases. This approach is an interesting alternative to traditional approaches and enriches the surgeon's therapeutic arsenal for managing these complex fractures.

The fascial connections of the pectineal ligament

In clinical settings, the pectineal ligament forms a basic landmark for surgical approaches. However, to date, the detailed fascial topography of this ligament is not well understood. The aim of this study was to describe the morphology of the pectineal ligament including its fascial connections to surrounding structures. The spatial-topographical relations of 10 fresh and embalmed specimens were dissected, stained, slice plastinated, and analyzed macroscopically, and in three cases histological approaches were also used. The pectineal ligament is attached ventrally and superiorly to the pectineus muscle, connected to the inguinal ligament by the lacunar ligament and to the tendinous origin of rectus abdominis muscle and the iliopubic tract. It forms a site of origin for the internal obturator muscle, and throughout its curved course, the ligament attaches to both the fasciae of iliopsoas and the internal obturator muscle. However, dorsally, these fasciae pass free from the bone, while the pectineal ligament itself is adhered to it. The organ fasciae are seen apart from the pectineal ligament and its connections. The pectineal ligament seems to form a connective tissue junction between the anterior and medial compartment of the thigh. This ligament, however, is free to other compartments arisen from the embryonal gut and to the urogenital ridge. These features of the pectineal ligament are important to consider during orthopedic and trauma surgical approaches, in gynecology, hernia and incontinence surgery, and in operations for pelvic floor and neovaginal reconstructions. Clin. Anat. 32:961-969, 2019. © 2019 Wiley Periodicals, Inc.

Modified Stoppa Approach for Acetabulum Fracture: A Review

Fracture acetabulum is a grave injury and a challenge for orthopedic surgeons. Anterior and posterior approaches have been described for fixation of acetabulum fractures. The modified Stoppa approach is considered an alternate to anterior approach, which provides access to pelvis from inside the cavity. The purpose of this article is to review the available literature on use of the modified Stoppa approach in acetabulum fractures. The available data suggest that modified Stoppa approach is useful in anterior acetabulum fractures and some posterior acetabulum fractures, especially where buttressing of medial wall is required.

Fixation of Displaced Acetabular Fractures With an Anatomic Quadrilateral Surface Plate Through the Stoppa Approach

Satisfactory fixation for displaced acetabular fractures involving the quadrilateral surface remains difficult to obtain with conventional reconstruction plates. To achieve minimally invasive management of fractures of the quadrilateral surface, the authors designed a type of anatomic quadrilateral surface plate (AQSP). A retrospective study to assess the therapeutic results of the AQSP was performed at their institution. A total of 26 patients with quadrilateral surface fractures fixed with an AQSP through the Stoppa approach from February 2014 to February 2015 were included in this study. There were 16 men and 10 women with a mean age of 37.5 years. The patients were followed for a mean of 28.81 months (range, 24-36 months). The mean operative time was 98.85±16.08 minutes, and the mean intraoperative blood loss was 353.85±124.84 mL. Postoperative radiographs and computed tomography scans showed that anatomic and good reductions were obtained in 88.46% (23 patients) and 11.54% (3 patients) of the patients, respectively. Screw loosening was not observed. All of the fractures healed well at a mean of 3.54 months. Two cases of obturator nerve injury and 1 case of corona mortis rupture were observed. However, permanent complications were not observed. The mean Merle d'Aubigné score at final follow-up was 16.38±1.33 points. The authors conclude that satisfactory fixation with the AQSP system can be achieved through the Stoppa approach. [Orthopedics. 2019; 42(2):e180-e186.].

Symmetry Matching of the Medial Acetabular Surface-A Quantitative Analysis in View of Patient-Specific Implants

OBJECTIVE

To quantify intrapelvic surface symmetry in reference to a preshaped suprapectineal acetabular implant.

METHODS

In this cross-sectional study, an anatomically preshaped acetabular fracture implant was fitted on 3D surface models of 516 pelvises from a preexisting bone database using a software tool for automated implant fitting (SOMA, Stryker Orthopaedic Modeling and Analytics) of a CAD model of the implant. The distances between bone and the reference implant were measured at 2310 reference points for each hemipelvis.

RESULTS

The average distance between the left hemipelvis and the plate was 1.98 mm (median, 10% percentile: 1.45, 90% percentile: 2.78) and 2.0 mm (median, 10% percentile: 1.45, 90% percentile: 2.92) between the right hemipelvis and the plate. There was no significant difference between the 2 hemipelvises (median absolute pairwise delta: 0.25 mm; 10% percentile: 0.04, 90% percentile: 0.82; Wilcoxon, P = 0.064).

CONCLUSIONS

With regard to the periacetabular surface of the inner pelvis, the pelvis can be considered sufficiently symmetric for using the mirrored contralateral hemipelvis as a template for patient-specific implants in acetabular fracture fixation.

Anterior subcutaneous internal fixator (INFIX) versus plate fixation for pelvic anterior ring fracture

The aim of this study was to compare the clinical outcomes in patients with unstable anterior pelvic ring fractures after treatment with anterior subcutaneous internal fixator (INFIX) or plate fixation. We performed a retrospective study from August 2015 to October 2017. A consecutive series of 74 patients who underwent surgical treatment of their anterior pelvic ring (35 treated with INFIX and 39 treated with plates) were studied. Data collected included patients' demographic data, injury severity score (ISS), AO/OTA classification, injury mechanism, time to surgery, procedure time, and blood loss. The quality of postoperative reduction were assessed by postoperative radiographs using the Tornetta and Matta method. Functional outcome was evaluated using Majeed scoring system. In the INFIX group, ten patients developed LFCN paralysis, one patient suffered from superficial infection. Three screw loosening cases and two wound infection cases occurred in the plate group. INFIX is relatively minimally invasive and time-saving than the reconstruction plate in the treatment of anterior pelvic ring fracture. However, plate fixation increases the rate of anatomic reduction of the pelvic anterior ring fracture. Plates also provide a higher functional outcome compared with INFIX. INFIX is especially suitable in patients with urological injury, which can also decrease the wound infection rate.

The Ilioinguinal Approach: State of the Art

INTRODUCTION

The ilioinguinal approach is the standard approach for the open reduction and internal fixation of the majority of displaced, anteriorly based acetabular fractures as it offers wide access to the acetabulum, is extensile, and has been associated with enhanced recovery.

INDICATIONS & CONTRAINDICATIONS

STEP 1 PREOPERATIVE PLANNING

Review the patient's general condition and imaging studies and plan the sequence of reduction and fixation.

STEP 2 PREPARATION AND PATIENT POSITIONING

Position the patient supine on the fracture table, induce anesthesia, prepare the surgical field, administer intravenous antibiotics, and apply traction.

STEP 3 ILIOINGUINAL APPROACH

Make a long curvilinear incision over the affected lower flank, develop the 3 working windows, and reduce and stabilize the fracture while protecting the neurovascular structures and the bladder (Video 2).

STEP 4 FRACTURE REDUCTION AND FIXATION

For reduction of a both-column acetabular fracture, connect the mobile parts of the acetabulum to the iliac segment that is attached to the sacrum, noting that, in most cases, the usual sequence involves the reduction of the anterior column to the intact ilium followed by the reduction of the posterior column (Video 7).

STEP 5 WOUND CLOSURE AND POSTOPERATIVE AFTERCARE

Perform meticulous hemostasis, apply drains, and ensure watertight closure, which are the final steps of the operation (Video 8).

RESULTS

The ilioinguinal approach remains 1 of the standard approaches for the management of acetabular fractures10.

PITFALLS & CHALLENGES

There Is No Column: A New Classification for Acetabular Fractures

BACKGROUND

The surgical treatment of acetabular fractures relies on the understanding of fracture architecture and their classification. The Judet and Letournel classification has been the cornerstone in understanding and treating acetabular fractures. Recently, there has been growing evidence of discrepancies and incompleteness in the Judet and Letournel classification, adversely affecting its clinical use. This study describes a novel comprehensive classification system that will direct surgical approach and fixation methods.

METHODS

A retrospective study of patients with acetabular fractures treated at a level-I trauma center also serving as a referral center for acetabular fractures was performed. Fractures were classified according to both the novel and Judet and Letournel classification systems. The novel classification developed integrates the displacement vector (posterior, superomedial, or combined) and the fractured anatomic structures (anteroposterior wall, pelvic brim, iliac wing, quadrilateral plate, and ischium). Furthermore, postoperative malreduction was evaluated on the basis of intra-articular gap measurements in either anteroposterior or Judet oblique views.

RESULTS

The study included 229 patients with acetabular fractures treated between 2007 and 2016. The mean patient age (and standard deviation) was 46.7 ± 21.75 years, and 172 patients (75.1%) were surgically treated. According to the novel classification system, the posterior displacement vector group included 60 patients, the superomedial displacement vector group included 130 patients, the combined displacement vector group included 36 patients, and 3 patients were unclassified by the new system. Forty-six patients (20.1%) could not be classified by the Judet and Letournel classification. Pelvic-brim fracture patterns were described as along the pelvic brim, across the pelvic brim, or comminuted. The quadrilateral plate primary fracture line was shown to be perpendicular to the pelvic brim. The selection of surgical approach and fixation methods depends on the fracture type.

CONCLUSIONS

This study presents a novel classification system for acetabular fractures. It offers a complete classification system, encompassing nearly all fracture patterns. As the selection of surgical approach and fixation methods depends on fracture classification and understanding, the novel classification system can aid the surgeon with decision-making.

The Anterior Intrapelvic Approach for Acetabular Fractures Using Approach-Specific Instruments and an Anatomical-Preshaped 3-Dimensional Suprapectineal Plate

OBJECTIVES

Anatomical acetabular plates the anterior intrapelvic approach (AIP) were recently introduced to fix acetabular fractures through the intrapelvic approach. Therefore, we asked the following: (1) Does the preshaped 3-dimensional suprapectineal plate interfere with or even impair the fracture reduction quality? (2) How often does the AIP approach need to be extended by the first (lateral) window of the ilioinguinal approach?

DESIGN

Observational case series.

SETTING

Two Level 1 trauma centers.

PATIENTS/PARTICIPANTS

Patients with unstable acetabular fractures in 2014.

INTERVENTION

Fracture fixation with anatomical-preshaped, 3-dimensional suprapectineal plates through the AIP approach ± the first window of the ilioinguinal approach.

OUTCOME MEASUREMENTS

Fracture reduction results were measured in computed tomography scans and graded according to the Matta quality of reduction. Intraoperative parameters and perioperative complications were recorded. Radiological results (according to Matta) and functional outcome (modified Merle d'Aubigné score) were evaluated at 1-year follow-up.

RESULTS

Thirty patients (9 women + 21 men; mean age ± SE: 64 ± 8 years) were included. The intrapelvic approach was solely used in 19 cases, and in 11 cases, an additional extension with the first window of the ilioinguinal approach (preferential for 2-column fractures) was performed. The mean operating time was 202 ± 59 minutes; the fluoroscopic time was 66 ± 48 seconds. Fracture gaps and steps in preoperative versus postoperative computed tomography scans were 12.4 ± 9.8 versus 2.0 ± 1.5 and 6.0 ± 5.5 versus 1.3 ± 1.7 mm, respectively. At 13.4 ± 2.9 months follow-up, the Matta grading was excellent in 50%, good in 25%, fair in 11%, and poor in 14% of cases. The modified Merle d'Aubigné score was excellent in 17%, good in 37%, fair in 33%, and poor in 13% of cases.

CONCLUSION

The AIP approach using approach-specific instruments and an anatomical-preshaped, 3-dimensional suprapectineal plate became the standard procedure in our departments. Radiological and functional early results justify joint preserving surgery in most cases.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Insertion of psoas minor tendon at pelvic brim, a novel anatomic landmark for extra-articular, screw placement through Stoppa approach

BACKGROUND

The psoas minor partially inserted to the superior pelvic brim. And the plate used to fix the acetabular fracture has always been positioned at the pelvic brim after reduction through the Stoppa approach. However, there are few studies depicting the clinical significance of the psoas minor. The purpose of this paper was to explore the relationship between the insertion of the psoas minor tendon at the pelvic brim (IPMTPB) and screw placement through the Stoppa approach.

MATERIALS AND METHODS

Fifteen cadavers were dissected for adequate exposure to IPMTPB in our study. However, not all specimens had a psoas minor. For the specimens with IPMTPB, the posterior and anterior edges were used as the first and second entry points, dividing the area from the sacroiliac joint to the pubic symphysis into three zones (d1, d2 and d3). The average proportion of each zone was obtained after measurement the three zones, to locate the two entry points for the specimens without a psoas minor. From the longitudinal Stoppa incision, the first wire was inserted horizontally, and the second wire was placed vertical to the bone surface. Fluoroscopy and computed tomography (CT) were conducted to examine the relationship between the wires and the acetabulum.

RESULTS

There was a psoas minor in sixteen hemipelvises (53.33%). After measurement and calculation, we determined that the average proportions of zones d1, d2, and d3 were 28.03%, 29.14%, and 42.83%, respectively. For all specimens, the wires were successfully inserted, and the trajectories of the wires were outside the hip joint cavity.

CONCLUSIONS

IPMTPB could be used as an anatomic landmark of safe zones for screw placement through the Stoppa approach. For cases without a psoas minor, the zones for extra-articular screw placement could be determined through the measurements in this paper.

The origins and current applications of classic eponymous terms for pelvic and acetabular fractures: A historic review

We present the historical background of 5 eponymous terms in pelvic and acetabular injury treatment. The eponymous terms Duverney fracture, Malgaigne fracture, Judet-Letournel classification, Kocher-Langenbeck approach and Stoppa approach are discussed. After presenting the original description by the coining author, a short biography of the author is given. For each eponymous term the current clinical implication is given and discussed afterwards.